bjsports-2011-090297.indd Editorial Bleakley CM, Glasgow P, MacAuley DC, et al. Br J Sports Med (2011). doi:10.1136/bjsports-2011-090297 1 of 2 The acronym PRICE (protection, rest, ice, compression and elevation) has been cen- tral to acute soft tissue injury management for many years despite a paucity of high- quality, empirical evidence to support the various components or as a collective treatment package. Treatment paradigms in sports medicine must be updated based on contemporary research evidence. As a recent example, the widespread use of non-steroidal anti-infl ammatory drugs in acute soft tissue injury management has been challenged, particularly with liga- ment and muscle injuries. 1 Ice compression and elevation (ICE) is the basic principle of early treatment. Most research has focused on the anal- gesic effect of icing or the associated skin or intramuscular temperature changes; a recent randomised controlled trial by Prins and colleagues, 2 which examined the effectiveness of ice on recovery from acute muscle tear, is the fi rst of its kind. Clinical studies into compression are also lacking, and much of its rationale is extrapolated from research relating to deep venous thrombosis prophylaxis and lymphoedema management; there is little clinical research on elevation. 3 Protection and rest after injury are sup- ported by interventions that stress shield , unload and/or prevent joint movement for various periods. Recent animal models 4 – 6 show that short periods of unloading are required after acute soft tissue injury and that aggressive ambulation or exer- cise should be avoided. But, rest should be of limited duration and restricted to immediately after trauma. Longer peri- ods of unloading are harmful and produce adverse changes to tissue biomechanics 1 Health and Rehabilitation Sciences Research Institute, University of Ulster, Jordanstown, Newtownabbey, UK 2 Sports Institute of Northern Ireland, University of Ulster, Jordanstown, Newtownabbey, UK 3 Association of Physiotherapists in Sports and Exercise Medicine, London, UK 4 UKCRC Centre of Excellence for Public Health (NI), Queens University Belfast, Royal Victoria Hospital, Belfast, UK Correspondence to C M Bleakley, Health and Rehabilitation Sciences Research Institute, University of Ulster, Jordanstown, Newtownabbey, County Antrim BT370QB, UK; chrisbleakley@hotmail.com PRICE needs updating, should we call the POLICE? C M Bleakley, 1,3 P Glasgow, 2,3 D C MacAuley 4 and morphology. Progressive mechani- cal loading is more likely to restore the strength and morphological characteris- tics of collagenous tissue. 4 5 Indeed, early mobilisation with accelerated rehabilita- tion is effective after acute ankle strain. 7 Functional rehabilitation of ankle sprain, which involves early weight-bearing usu- ally with an external support, is superior to cast immobilisation for most types of sprain severity. 8 9 Functional rehabilitation aligns well with the principles of mechanotherapy, whereby mechanical loading prompts cellular responses that promote tissue structural change. 10 There are consistent fi ndings from animal models that dem- onstrate how mechanical loading upregu- lates mRNA expression for key proteins associated with soft tissue healing. 4 – 6 The diffi cult clinical challenge is fi nding the balance between loading and unloading during tissue healing. If tissues are stressed too aggressively after injury, the mechani- cal insult may cause re-bleeding or further damage. Protection of vulnerable tissues therefore remains an important principle. But, too much emphasis creates a default mindset that loading has no place in acute management. Rest may be harmful and inhibits recovery. The secret is to fi nd the ‘optimal loading’. Optimal loading means replacing rest with a balanced and incremental reha- bilitation programme where early activity encourages early recovery. Injuries vary so there is no single one size fi ts all strategy or dosage. A loading strategy should refl ect the unique mechanical stresses placed upon the injured tissue during functional activi- ties, which varies across tissue type and anatomical region. For example, a muscle injury to the lower limb has cyclic loading through normal ambulation. The upper limb may require additional cyclic load to be factored into the rehabilitation program in order to maximise mechanical stimulus. POLICE, a new acronym, which rep- resents protection, optimal loading, ice compression and elevation, is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury man- agement. Optimal loading is an umbrella term for any mechanotherapy interven- tion and includes a wide range of manual techniques currently available; indeed the term may include manual techniques such as massage refi ned to maximise the mech- ano-effect. Paradoxically, crutches, braces and supports, traditionally associated with rest, may have a greater role in adjusting and regulating optimal loading in the early stages of rehabilitation. POLICE should make us think more about research into designing rehabilita- tion strategies that are appropriate to the nature and severity of injury in different sports and activities. If the primary princi- ple of treatment is to restore the histologi- cal and mechanical properties of injured soft tissue, optimal loading may indeed be sport specifi c. The challenge is in deter- mining what is ‘optimal’ in terms of the dosage, nature and timing. POLICE is not just an acronym to guide management but a stimulus to a new fi eld of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by com- pression and elevation are enough to retain ICE within the acronym. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Accepted 3 August 2011 REFERENCES 1. Paoloni JA , Milne C , Orchard J , et al . Non- steroidal anti-infl ammatory drugs in sports medicine: guidelines for practical but sensible use. Br J Sports Med 2009 ; 43 : 863 – 5 . 2. Prins JC , Stubbe JH , van Meeteren NL , et al . Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: a pilot randomized controlled trial. Clin Rehabil 2011 ; 25 : 433 – 41 . 3. Bleakley CM , Glasgow PD , Philips P , et al ; for the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSM). Guidelines on the Management of Acute Soft Tissue Injury Using Protection Rest Ice Compression and Elevation. London: ACPSM, 2011:15–21. 4. Bring DK , Reno C , Renstrom P , et al . Joint immobilization reduces the expression of sensory neuropeptide receptors and impairs healing after tendon rupture in a rat model. J Orthop Res 2009 ; 27 : 274 – 80 . 5. Martinez DA , Vailas AC , Vanderby R Jr , et al . Temporal extracellular matrix adaptations in ligament during wound healing and hindlimb unloading. Am J Physiol Regul Integr Comp Physiol 2007 ; 293 : R1552 – 60 . 6. Eliasson P , Andersson T , Aspenberg P . Rat Achilles tendon healing: mechanical loading and gene expression. J Appl Physiol 2009 ; 107 : 399 – 407 . 7. Bleakley CM , O’Connor SR , Tully MA , et al . Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 2010 ; 340 : c1964 . 8. Jones MH , Amendola AS . Acute treatment of inversion ankle sprains: immobilization versus BJSM Online First, published on September 7, 2011 as 10.1136/bjsports-2011-090297 Copyright Article author (or their employer) 2011. Produced by BMJ Publishing Group Ltd under licence. group.bmj.com on January 22, 2016 - Published by http://bjsm.bmj.com/Downloaded from http://bjsm.bmj.com/ http://group.bmj.com Editorial Bleakley CM, Glasgow P, MacAuley DC, et al. Br J Sports Med (2011). doi:10.1136/bjsports-2011-0902972 of 2 functional treatment. Clin Orthop Relat Res 2007 ; 455 : 169 – 72 . 9. Kerkhoffs GM , Rowe BH , Assendelft WJ , et al . Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 2002 ; 3 :CD003762. 10. Khan KM , Scott A . Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009 ; 43 : 247 – 52 . group.bmj.com on January 22, 2016 - Published by http://bjsm.bmj.com/Downloaded from http://bjsm.bmj.com/ http://group.bmj.com POLICE? PRICE needs updating, should we call the C M Bleakley, P Glasgow and D C MacAuley published online September 7, 2011Br J Sports Med http://bjsm.bmj.com/content/early/2011/09/07/bjsports-2011-090297 Updated information and services can be found at: These include: References #BIBL http://bjsm.bmj.com/content/early/2011/09/07/bjsports-2011-090297 This article cites 8 articles, 6 of which you can access for free at: service Email alerting box at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in the Collections Topic Articles on similar topics can be found in the following collections (84)Drugs: musculoskeletal and joint diseases (807)Trauma (906)Injury (266)Editor's choice Notes http://group.bmj.com/group/rights-licensing/permissions To request permissions go to: http://journals.bmj.com/cgi/reprintform To order reprints go to: http://group.bmj.com/subscribe/ To subscribe to BMJ go to: group.bmj.com on January 22, 2016 - Published by http://bjsm.bmj.com/Downloaded from http://bjsm.bmj.com/content/early/2011/09/07/bjsports-2011-090297 http://bjsm.bmj.com/content/early/2011/09/07/bjsports-2011-090297#BIBL http://bjsm.bmj.com/content/early/2011/09/07/bjsports-2011-090297#BIBL http://bjsm.bmj.com//cgi/collection/editors_choice http://bjsm.bmj.com//cgi/collection/injury http://bjsm.bmj.com//cgi/collection/trauma http://bjsm.bmj.com//cgi/collection/drugs_musculoskeletal_and_joint_diseases http://group.bmj.com/group/rights-licensing/permissions http://journals.bmj.com/cgi/reprintform http://group.bmj.com/subscribe/ http://bjsm.bmj.com/ http://group.bmj.com